Measure #411 (NQF 0711): Depression Remission at Six Months– National Quality Strategy Domain: Effective Clinical Care

2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

MEASURE TYPE: Outcome

DESCRIPTION: Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

INSTRUCTIONS: This measure is to be reported once per performance period for patients seen during the denominator identification measurement period with a diagnosis of depression and an initial PHQ-9 greater than nine. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and an index date PHQ-9 Score greater than 9 documented during the denominator identification measurement period dates of 12/1/2015 to 11/30/2016. Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis.

Measure Reporting: The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

DENOMINATOR: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine

Definition: Index Date - The first instance (12/1/2015 to 11/30/2016) of elevated PHQ-9 greater than 9 and diagnosis of depression or dysthymia

Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years AND Diagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1 AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439 AND Index date PHQ-9 Score greater than 9 documented during the twelve month denominator identification period: G9511 AND NOT

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DENOMINATOR EXCLUSIONS: Patients who died OR Patients who received hospice or palliative care service OR Patients who were permanent nursing home residents OR Patients with a diagnosis of bipolar disorder OR Patients with a diagnosis of personality disorder

NUMERATOR: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five

Definitions: Remission - a PHQ-9 score less than five. Six Months - the point in time from the index date extending out six months (+/- 30 days). Any PHQ-9 score less than five obtained during this two month period is deemed as remission at six months, values obtained prior to or after this period are not counted as numerator compliant (remission).

Numerator Options: Performance Met: Remission at six months as demonstrated by a six month

(+/-30 days) PHQ-9 score of less than five (G9573) OR

Performance Not Met: Remission at six months not demonstrated by a six month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to five (G9574)

RATIONALE The Centers for Disease Control and Prevention states that nationally 15.7% of people report being told by a health care professional that they had depression at some point in their lifetime. Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily. According to National Institute of Mental Health (NIMH), 6.7 percent of the U.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 - 44. Additionally, dysthymia accounts for an additional 3.3 million Americans.

CLINICAL RECOMMENDATION STATEMENTS: Improvement in the symptoms of depression and an ongoing assessment of the current treatment plan is crucial to the reduction of symptoms and psychosocial well-being of patients with major depression. Most people treated for initial depression need to be on medication at least six to twelve months after adequate response to symptoms, patients with recurrent depression need to be treated for three years or more and response with psychotherapy can take eight to twelve weeks of regular and frequent therapy to show improvement. Remission is defined as a PHQ-9 score of less than five at twelve months. The Patient Health Questionnaire (PHQ-9) tool is a widely accepted, standardized tool [Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.] that is completed by the patient, ideally at each visit, and utilized by the provider to monitor treatment progress. This tool was selected for measuring outcomes for this population because it is 1) validated with a sensitivity of .080 and a specificity of 0.92 with substantial heterogeneity I2 = 82%, 2) widely accepted and utilized in Minnesota, 3) available for clinical use, 4) translated into many languages and 5) easy for the patient to complete and the provider to score. Available at PHQ Screeners Website

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This nine question tool contains the following questions which are scored on a scale of 0 to 27 based on the scale of Not at All (0), Several Days (1), More Than Half the Days (2), or Nearly Every Day (3) for responses to the questions over the last 2 weeks.

• Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself - or that you are a failure or have let yourself or your family down • Trouble concentrating on things, such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or

restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way

Source: ICSI Guideline for Major Depression in Adults in Primary Care 16th edition September 2013 ICSI Guideline For Major Depression in Adults in Primacy Care Guideline Web PDF

COPYRIGHT: © MN Community Measurement, 2016. All rights reserved.

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2017 Registry Individual Measure Flow #411 NQF#0711: Depression Remission at Six Months

Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure.

1. Start with Denominator

2. Check Patient Age:

a. If the Age is greater than or equal to 18 years of age on Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is greater than or equal to 18 years of age on Date of Service and equals Yes during the measurement period, proceed to check Patient Diagnosis.

3. Check Patient Diagnosis:

a. If Diagnosis of Depression as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Diagnosis of Depression as Listed in the Denominator equals Yes, proceed to check Current Encounter Performed.

4. Check Encounter Performed:

a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Encounter as Listed in the Denominator equals Yes, proceed to check Index Date PHQ-9 Score Greater Than 9 Documented During the 12 Month Denominator Identification Period.

5. Check Index Date PHQ-9 Score Greater Than 9 Documented During the 12 Month Denominator Identification Period:

a. If Index Date PHQ-9 Score Greater Than 9 Documented During the 12 Month Denominator Identification Period equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Index Date PHQ-9 Score Greater Than 9 Documented During the 12 Month Denominator Identification Period equals Yes, proceed to check Patients Who Died.

6. Check Patients Who Died:

a. If Patients Who Died equals No, proceed to check Patients Who Received Hospice or Palliative Care Services.

b. If Patients Who Died equals Yes, do not include in Eligible Patient Population. Stop Processing.

7. Check Patients Who Received Hospice or Palliative Care Services:

a. If Patients Who Received Hospice or Palliative Care Services equals No, proceed to check Patients Who were Permanent Nursing Home Residents.

b. If Patients Who Received Hospice or Palliative Care Services equals Yes, do not include in Eligible Patient Population. Stop Processing.

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8. Check Patients Who were Permanent Nursing Home Residents:

a. If Patients Who were Permanent Nursing Home Residents equals No, proceed to check Patients With Diagnosis of Bipolar Disorder.

b. If Patients Who were Permanent Nursing Home Residents equals Yes, do not include in Eligible Patient Population. Stop Processing.

9. Check Patients With Diagnosis of Bipolar Disorder:

a. If Patients With Diagnosis of Bipolar Disorder equals No, proceed to check Patients With Diagnosis of Personality Disorder.

b. If Patients With Bipolar Disorder equals Yes, do not include in Eligible Patient Population. Stop Processing.

10. Check Patients With Diagnosis of Personality Disorder:

a. If Patients With Diagnosis of Personality Disorder equals No, include in Eligible population.

b. If Patients With Personality Disorder equals Yes, do not include in Eligible Patient Population. Stop Processing.

11. Denominator Population:

a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation.

12. Start Numerator

13. Check Remission at Six Months as Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five:

a. If Remission at Six Months as Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five equals Yes, include in Data Completeness Met and Performance Met.

b. Data Completeness Met and Performance Met letter is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in Sample Calculation.

c. If Remission at Six Months as Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five equals No, proceed to Remission at Six Months Not Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five. Either PHQ-9 Score was Not Assessed or is Greater than or Equal to 5.

14. Check Remission at Six Months Not Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five. Either PHQ-9 Score was Not Assessed or is Greater than or Equal to 5:

a. If Remission at Six Months Not Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five. Either PHQ-9 Score was Not Assessed or is Greater than or Equal to 5 equals Yes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter c equals 3 patients in the Sample Calculation.

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c. If Remission at Six Months Not Demonstrated by a Six Month (+/-30 days) PHQ-9 Score of Less Than Five. Either PHQ-9 Score was Not Assessed or is Greater than or Equal to 5 equals No, proceed to Data Completeness Not Met.

15. Check Data Completeness Not Met:

a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 patient has been subtracted from the data completeness numerator in the sample calculation.

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